Are You A Carer?

Do you look after a family member or friend who is unwell, disabled or frail?

If so please complete this form. Once you are added to our list of carers we will
know about your busy life as a carer, which can affect your health. We can also
try and be flexible with appointments etc as we will know about your commitments.

Carer Details

Title

MrMrsMissMs

First Name(s)

Surname

Address

Postcode

Date of Birth

Email Address

Telephone

Details of Person Being Cared For

Title

MrMrsMissMs

First Name(s)

Surname

Address

Postcode

Date of Birth

What relation is the person you care for?

Is the person you care for a patient at Drs Clokey & McShane?

YesNo

About This Form

Fields marked with a red asterisk arecompulsory.

If you care for more than one person please complete another form.

The information you supply us will be used lawfully, in accordance with GDPR Regulations. GDPR gives you the right to know what information is held about you, and sets out rules to make sure that this information is handled properly.

Please note that by using this form you will be sending information about yourself
across the Internet. Whilst every effort is made to keep this information secure,
you should be aware that we cannot offer any guarantees of absolute privacy. If
this matter concerns you then you should use another method of registration.

Personal information retained on this system is stored in a secure data centre located
in the UK and is treated as confidential.